Att C - Indiana Economic Impact Form.xls
XLS spreadsheet 196 KB Posted
- Attached to
- Automated Fingerprint Identification SystemBid Documents State and local contract opportunity
- Solicitation number
- 27-85295
- Issued by
- Marion County, Indiana
About this file
This is an Indiana Economic Impact Form (Attachment C) required by the Indiana Department of Administration for all contractors, vendors, and suppliers conducting business with State of Indiana agencies. The form serves to document the economic impact a project will have on Indiana and its residents, regardless of the contractor's location. Completion of all 22 items is mandatory and includes basic company information such as legal name, address, telephone, federal tax identification number, state/country of domicile, parent company details, and relevant department account numbers from the Indiana Department of Workforce Development and Department of Revenue. The form also requires submission of current payroll data from the most recently completed IRS Form W-2 distribution, including the total number of Indiana resident employees and total payroll amounts for both Indiana residents and all employees.
The form's primary focus is accounting for Full Time Equivalent (FTE) employees who are Indiana residents working specifically on the proposed or current contract. Respondents must populate detailed worksheets identifying all job titles, number of employees, contract duration in months, percentage of time spent on the contract, and resulting FTE calculations for both prime contractors and subcontractors. The state defines FTE as a productivity measurement where partial allocations apply when employees split time across multiple contracts; for example, ten employees working on four contracts would each count as 0.25 FTE on the state contract. The initial contract term is noted as 24 months for calculation purposes. An authorized official must affirm under penalties of perjury that all representations are accurate, with signature, printed name, title, and date required for submission.
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Text version
Instructions
| Indiana Economic Impact Form, Attachment C |
| Instructions |
| 1. Complete lines 1 - 15 with the information requested about the company in the Attachment C worksheet. |
All companies desiring to do business with state agencies must complete an “Indiana Economic Impact” form (Attachment C). The collection and recognition of the information collected with the Indiana Economic Impact form places a strong emphasis on the economic impact a project will have on Indiana and its residents regardless of where a business is located. The collection of this information does not restrict any company or firm from doing business with the state.
2. Line 16: Enter total amount of this proposal, bid, or current contract.
This figure is the respondent's total cost proposal to the the state (as sumitted in Attachment D, Cost Proposal Template).
3. Lines 18 and 21 measure the full-time equivalent (FTE) count of Indiana residents; this number will be auto-populated on Attachment C worksheet. Respondents shall populate the yellow-shaded cells in the FTE Details worksheet.
The state defines FTE as a measurement of an employee's productivity on a specific project or contract. An FTE of 1 would mean that there is one worker fully engaged on a project. If there are two employees each spending 1/2 of their working time on a project that would also equal 1 FTE.
Please populate the yellow-shaded cells in the FTE Details worksheet.
Respondents shall provide a job title for each of the FTE's proposed for The State of Indiana contract as well as the number of FTE that job title contributes to the total.
PROJECT MANAGER - 1 FTE
Please keep in mind that the only FTE's that should be included in this count are Indiana employees working on this contract ONLY. If there are 10 employees working on this contract but they are splitting their time with numerous other contracts as well, then these employees cannot be counted as 1 FTE. Instead, these employees should be counted as a fraction of an FTE. For example: 10 employees working on 4 contracts (1 of them being the State of Indiana contract) - each of the 10 employees would only count as 1/4 of an FTE or .25. Therefore, the total number of FTE's for this scenario would be 2.5.
Attachment C
| This information is required by the Indiana Department of Administration for all contractors, vendors/suppliers to the State of Indiana (complete all 22 items). | |||||
| 1 | Legal Name of firm: | ||||
| 2 | Address/City/State/Zip Code: | ||||
| 3 | Telephone #/Fax #/Website: | ||||
| 4 | Federal Tax Identification Number: | ||||
| 5 | State/Country of domicile/incorporation: | ||||
| 6 | Location of firm's headquarters or principal place of business: | ||||
| 7 | Name of parent company or holding company (if applicable): | ||||
| 8 | State/Country of domicile/incorporation of company listed in #7: | ||||
| 9 | Address of company listed in #7: | ||||
| 10 | IN Department of Workforce Development (DWD) account number: | ||||
| 11 | IN Department of Revenue (DOR) account number: | ||||
| 12 | Number of Indiana resident employees per most recently completed IRS Form W-2 distribution: | ||||
| 13 | Total number of employees per most recently completed IRS Form W-2 distribution: | ||||
| 14 | Total amount of payroll paid to Indiana resident employees per most recently completed IRS Form W-2 distribution: | ||||
| 15 | Total amount of payroll paid to all employees per the most recently completed IRS Form W-2 distribution: | ||||
| 16 | Total amount of this proposal, bid, or current contract: | ||||
| ACCOUNTING OF INDIANA RESIDENT EMPLOYEES | |||||
| 17 | Prime Contractor Company Name: | ||||
| 18 | Number of Full Time Equivalent (FTE) employees that are Indiana residents specifically for this proposal or contract: | 0.00 | |||
| 19 | Subcontractor Company Name: | ||||
| 20 | Address/Contact Person/Telephone Number/Tax ID Number: | ||||
| 21 | Number of Full Time Equivalent (FTE) employees that are Indiana residents specifically for this proposal or contract: | 0.00 | 0.00 | 0.00 | 0.00 |
| 22 | Affirmation by authorized official: I affirm under penalties of perjury that the foregoing representations are true to be the best of my knowledge and belief: | ||||
| Signature: | |||||
| Name of auththorized official: | |||||
| Title: | |||||
| Date: |
INDIANA ECONOMIC IMPACT - PROPOSALS AND CONTRACTS
State Form 51778 (R4 / 1-06)
DEPARTMENT OF ADMINISTRATION
Approved by State Board of Accounts, 2006
FTE Details
FTE DETAILS
Job Titles and Contributing FTE
- Populate the yellow-shaded cells; with all applicable job titles and the total FTE count.
- Respondents may insert additional rows to account for all job titles attributing to the total FTE count.
Please keep in mind that the only FTE's that should be included in this count are Indiana employees working on this contract ONLY. If there are 10 employees working on this contract but they are splitting their time with numerous other contracts as well, then these employees cannot be counted as 1 FTE. Instead, these employees should be counted as a fraction of an FTE. For example: The project length of the contract is 24 months. There are 10 employees working on the contract over the 24 month contract period. 5 employees are working solely on the project for 24 months. 3 employees are working equal time on 2 projects for 24 months. 2 employees are working solely on the project for 6 months.
The FTEs would be calculated as follows:
5 employees x 24 months (24 months working solely on this project) x 1 (time spent solely on this project) = 120 months / 24 months (length of contract) = 5 FTEs 3 employees x 24 months x .5 (splitting time equally between 2 projects) = 36 months / 24 months = 1.5 FTEs 2 employees x 6 months (6 months dedicated solely to this project) x 1 (time spent solely on this project) = 12 months / 24 months = .5 FTEs Column Title Definitions:
Number of Employees = Number of employees working on this State contract.
Duration (In Months) = Amount of time that the employee(s) will spend on the State contract.
Time Spent (Percentage) = Percentage of time the employee(s) will be working on the contract.
| Duration of Initial Contract Term (In Months) | 24 | *Number based on initial contract term | ||
| PRIME CONTRACTOR COMPANY | ||||
| EMPLOYEE JOB TITLE | Number of Employees | Duration (In Months) | Time Spent (Percentage) | NUMBER OF FTE |
| Example: Project Managers | 5 | 24 | 100% | 5.00 |
| Example: Project Coordinators | 3 | 24 | 50% | 1.50 |
| Example: Project Directors | 2 | 6 | 100% | 0.50 |
| 0.00 | ||||
| 0.00 | ||||
| 0.00 | ||||
| 0.00 | ||||
| 0.00 | ||||
| 0.00 | ||||
| 0.00 | ||||
| 0.00 | ||||
| TOTAL FTE COUNT | 0.00 | |||
| SUB CONTRACTOR COMPANY NAME | (Enter Company Name Here) | |||
| JOB TITLE | Number of Employees | Duration (In Months) | Time Spent (Percentage) | NUMBER OF FTE |
| Example: Developer | 2 | 6 | 100% | 0.50 |
| 0.00 | ||||
| 0.00 | ||||
| 0.00 | ||||
| TOTAL FTE COUNT | 0.00 | |||
| SUB CONTRACTOR COMPANY NAME | (Enter Company Name Here) | |||
| JOB TITLE | Number of Employees | Duration (In Months) | Time Spent (Percentage) | NUMBER OF FTE |
| Example: Developer | 2 | 6 | 100% | 0.50 |
| 0.00 | ||||
| 0.00 | ||||
| 0.00 | ||||
| TOTAL FTE COUNT | 0.00 | |||
| SUB CONTRACTOR COMPANY NAME | (Enter Company Name Here) | |||
| JOB TITLE | Number of Employees | Duration (In Months) | Time Spent (Percentage) | NUMBER OF FTE |
| Example: Developer | 2 | 6 | 100% | 0.50 |
| 0.00 | ||||
| 0.00 | ||||
| 0.00 | ||||
| TOTAL FTE COUNT | 0.00 | |||
| SUB CONTRACTOR COMPANY NAME | (Enter Company Name Here) | |||
| JOB TITLE | Number of Employees | Duration (In Months) | Time Spent (Percentage) | NUMBER OF FTE |
| Example: Developer | 2 | 6 | 100% | 0.50 |
| 0.00 | ||||
| 0.00 | ||||
| 0.00 | ||||
| TOTAL FTE COUNT | 0.00 |
File details come from the government source that posted it. Updated .